Active surveillance for 8 years, now have gleason 3+4

So I was first diagnosed in late 2013, see my history below. It was only low volume gleason 6, and I was comfortable with active surveillance. However, PSA started inching up in 2020. Recent PSA was 5.16. MRI showed that 7mm unconcerning lesion had grown was now a more concerning-looking 15 mm lesion.

Recent biopsy revealed gleason 3+4 in the lesion: Gleason score 3+4=7 (grade group 2, pattern 4: 5%) involving 2 of 2 cores (combined:9 mm, 30%)

Has anyone had luck with any treatment other than radical prostatectomy at my age (50)? Any other treatment options I should consider?

Thanks!

-Jason

Yes. Several radiation therapies are available to you with efficacy as good or better than surgery with usually less significant negative treatment side effects. HDR brachytherapy and SBRT external beam radiation therapy are excellent for your risk classification.

You should seek to interview specialist radiation oncologists in these specialties for an assessment. Where are you located? We may be able to identify specialists for you.

halbert said...
JRK,

First, congrats on 8 years of AS. That counts as success right away!
Second, I'd suggest you have your latest biopsy slides sent to Johns Hopkins for second opinion. It's not super common for G6 to turn to G7, so a confirmation is a good idea.
....

Halbert, I'm not following your statement about disease progression among G6 (GGG 1) men on AS. For example:

Disease progression and competing mortality for men undergoing active surveillance for low-risk prostate cancer. (2022 ASCO Symposium)

"Results: The cohort included 8562 men with low-risk PC. Pathologic upgrading to ≥GG2 and ≥GG3 occurred in 3227 and 1200 men, respectively. For all patients, the 8-year cumulative incidence of metastases and PCSM was 0.8% (95% CI: 0.6-1.0%) and 0.4% (CI:0.3-0.6%), respectively. Pathologic upgrading to ≥GG2 was associated with an increased risk of metastases at 8 years (1.2% vs 0.5%, p < 0.001).
...
Conclusions: For men with low-risk PC on active surveillance, pathologic upgrading was associated with a small increased risk of metastases but no increased risk of death from prostate cancer."
------------------------------------------

PCa is a heterogeneous disease, and disease progression is a major reason that so many in AS are, at some point, advised to seek treatment. Fortunately, very few men who follow their AS protocol slip though the cracks and go on to metastatic disease. However, the prospect of disease progression (along with missed higher-grade lesions) are two reasons that some men with low-burden G6 diagnoses choose to treat instead of going on AS.

That said, I second your advice for getting a 2nd opinion on the G7 biopsy is prudent.

Djin

Just wondering, I've had many biopsies, so this last one was targeted, but there were still 8 or more cores total. The two referenced were into the lesion that had been shown on the MRI.

JW…I was 69 at diagnosis; but, feeling like 50 and found SBRT a great option. A total of only eight visits to Cleveland Clinic including my initial consult where I hand carried my biopsy slides for a second and third opinion. A second visit for markers, a third for simulation and the last five for tha actual radiation. A simple, effective, safe, and painless process. Only some minor urinary burning that lasted for about ten days and did not require any prescription medication. On bowel issues…not so much as a wet fart. The volume of ejaculate is significantly reduced; however, orgasm is as pleasant as ever. Be glad to answer question.

Whether cells with pattern 4 and 5 potential form from mutations arising from the division of healthy cells, pre-cancerous cells, or existing pattern 3 or 4 cells is of importance for researchers trying to understanding how PCa works, but is really irrelevant to the concept of heterogenerous disease for us patients: some men won't progress from having only G6 lesions, some will, and many will already have lesions with a mix of grades at the time of diagnosis. "Progession" AFAIK simply means you have lesions with a higher grade than what you previously had.

Djin

Post Edited (DjinTonic) : 3/10/2022 8:51:14 PM (GMT-7)

Hi Jason and welcome back. First of all congrats on 8 years of AS. While your cancer has progressed somewhat, at least you got 8 good years w/o any active treatment. In the meantime your treatment options have improved so it's a win-win.

As others have suggested, you should get a second opinion on your pathology from Dr. Epstein at JHU. See if he agrees that you have the G7 or perhaps it's just a little more G6. Armed with that knowledge you can proceed with a treatment plan. Other than surgery, which will most likely cure you. you should also consult with experts in LDR Brachytherapy, HDR Brachytherapy and SBRT. Those radiation options are also likely to cure you with a better possibility of avoiding onerous side effects.

If you haven't done so, there are multiple good books about our cancer that I can suggest. Dr. Walsh, "Guide to Surviving Prostate Cancer" and Dr. Scholz, "Invasion of the Prostate Snatchers" and "Key to Prostate Cancer" will provide a good overall perspective. Speaking of Dr. Scholz, he is a prostate oncologist with no investment in either a robot or a radiation machine. Here is a video with his perspective on the choice between surgery and radiation:
https://www.youtube.com/watch?v=pya8n78br7s

Good luck in you decision making.

Jim

Jason, do you have BPH? Any urinary issues?

Central PA, yes I've got a weak stream that I know taking out the prostate would cure. But, just very concerned about possible ED issues.

Duke, who did you see at MD Anderson? As I understand it they address your case as a group, with surgeon, radiologist, etc and you get advised on every option. Is that how it worked? I like my Dr. here, Dr. Roehrborn at UT Southwestern, but he comes from only the surgical perspective.

Tudpock, thank's for the book suggestions. I have Walsh but will get the other. And I will get the second opinion on the biopsy results.

JRK said...
Central PA, yes I've got a weak stream that I know taking out the prostate would cure. But, just very concerned about possible ED issues.

I ask because our cases are similar in that I am a 3+4=7, grade group 2, single lesion, 5% grade 4, BPH person also. Instead of the AS protocol I’ve been on the BI (blissful ignorance) plan up until a couple of months ago.

My current plan, with the approval of my Uro, is to meet with another Uro who does the HoLEP procedures and look at hollowing out my prostate, with a key question being will he remove the lesion when he does so. If so, then at worst my prostate will be greatly reduced in size, my urinary problems will be gone, my PSA will be greatly lowered and more sensitive to PCa, I will have a thorough pathology of the prostate, and I will be an ideal candidate for RT. No effect to ED function. Of course, it is a procedure with attendant risks.

Best case, the cancer is fully removed and I continue on AS until I’m too old to care.

Just putting the thought out there. I meet with the HoLEP guy in two weeks. Will report back.

JRK - Going back to a previous question, proton therapy is a radiation treatment, protons vs. photons otherwise the same concepts.

You just need to read up on all the treatment options then meet with the appropriate doctors. You appear to be lucky, any treatment should fix your PCa problem. Just a matter of reducing the long list down to a couple of treatments that make the most sense to you.

Some easier reading can be found here:

https://www.pcf.org/guide/prostate-cancer-patient-guide/

I’ve never gotten the impression from these threads that all of the posts are 100% altruistic.

Each man is as different as the treatments.

That’s the view from the nose bleed section…

Take care

JRK said...
I am sending off the biopsy results to Johns Hopkins. Then I'm going to MD Anderson to meet with an expert in each area. It really sounds like they've made a lot of advances in radiation in the last ten years, so maybe that will be a consideration, whereas from the research I did 8 years ago, at my age then (42) I don't think I would have considered it.

Excellent plan. Something my urologist told me is to be prepared for surgeons to try to talk you into surgery, radiation oncologists to try to talk you into radiation, etc. I chose the robotic RP for the following reasons, which represents the underpinnings of my personal choice:
- My biopsy showed PCa in 12 out of 17 cores. While none of the cancer was greater than 3+4=7, the fact that it has spread in the general direction towards the perimeters is worrisome -- I want the beast removed.
- If I chose radiation, surgery would be out of the question in the future. However, if I chose surgery -- radiation remains an option later.
- In my case, I have a 57 percent chance that my PCa is organ-confined, and a 41 percent chance of extracapsular extension. That being said, my probability of survival after RP is 99 percent at both the 10 and 15 year marks. My odds of being progression-free after 5 years is 91 percent, and 85 percent after 10 years. To get these numbers, the doctor input my medical information into a Sloan Kettering Cancer Center prediction tool. This was extremely helpful in the decision-making process.
- I want to have the best chance of being disease-free -- and knowing it. With a RP, my PSA should crater to zero and stay there. With radiation, it's a little less definitive.
- For me, the alternative and experimental treatments (e.g. cryotherapy, etc.) would almost certainly have a less favorable outcome.
- My GP, who has no dog in this fight other than advocating for my health, rattled off a list of radiation side-effects (even with the newer systems) that -- for my age -- gave me pause. She was strongly in favor of the robotic RP.

As the saying goes, "your mileage may vary". The above represents my personal decision based on my own situation. I'm in the "unfavorable intermediate" category and aggressive treatment is a wiser choice.